﻿<!DOCTYPE html>
<html lang="en">
<#include "../include/resource-head.ftl"/>
<#assign active='siteAdd'/>
<body>
<#include "../include/common-top.ftl"/>
<div class="main-container" id="main-container">
    <div class="main-container-inner">
    <#include "../include/common-menu.ftl"/>
        <div class="main-content">
            <div class="page-content">
                <div class="col-xs-12">
                    <div class="row-fluid">
                        <div class="widget-box">
                            <div class="widget-header widget-header-blue widget-header-flat">
                                <h4 class="lighter">
                                    <i class="icon-plus"></i>信息录入
                                </h4>
                            </div>
                            <div class="widget-body">
                                <div class="widget-main">
                                    <div class="step-content row-fluid position-relative">
                                        <form class="form-horizontal" action="/info/add" method="post" enctype="multipart/form-data">
                                            <div class="col-xs-4">
                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">血压（收缩压）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="xyss" required/>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">血压（舒张压）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="xysz" required/>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">心率（次/分钟）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="xl"  required/>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">血糖（空腹）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="xt" required placeholder=""/>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">身高（cm）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="sg" required />
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">体重（kg）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="tz" required/>
                                                    </div>
                                                </div>
                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">胆固醇（mmol/L）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="dgc" required/>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="col-xs-4">

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">BMI</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="bmi" required/>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">视力（左眼）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="slz" required/>
                                                    </div>
                                                </div>


                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">视力（右眼）</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="text" class="width-100" name="sly" required/>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">辨色能力</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="bsnl">
                                                            <option value="正常">正常</option>
                                                            <option value="稍弱">稍弱</option>
                                                            <option value="弱">弱</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">心脏</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="xz">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-5 control-label no-padding-right">肺脏</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="fz">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                            </div>

                                            <div class="col-xs-4">

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">四肢</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="sz">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">淋巴</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="lb">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">甲状腺</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="jzx">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">嗅觉</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="xj">
                                                            <option value="正常">正常</option>
                                                            <option value="稍弱">稍弱</option>
                                                            <option value="弱">弱</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">血常规</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="xdt">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">彩超</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <select class="width-100" name="cc">
                                                            <option value="正常">正常</option>
                                                            <option value="异常">异常</option>
                                                        </select>
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">血常规</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="file" name="icon"  class="form-control">
                                                    </div>
                                                </div>

                                                <div class="form-group has-info">
                                                    <label class="col-xs-12 col-sm-3 control-label no-padding-right">彩超</label>
                                                    <div class="col-xs-12 col-sm-5">
                                                        <input type="file" name="icon2"  class="form-control">
                                                    </div>
                                                </div>

                                            </div>




                                            <hr/>
                                            <div class="row-fluid wizard-actions">
                                                <button class="btn btn-info" type="button" onclick="javascript:history.go(-1)">返回</button>
                                                <button class="btn" type="reset">重置</button>
                                                <button class="btn btn-success" type="submit">提交</button>
                                            </div>

                                        </form>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
        </div><!-- /.page-content -->
    </div><!-- /.main-content -->
</div><!-- /.main-container -->
</body>
<#include "../include/resource-script.ftl"/>
</html>

